Non-invasive cardiac output monitoring for cesarean delivery under epidural anesthesia in a patient with Marfan syndrome and cardiomyopathy.

Maternal cardiac output and stroke volume increase significantly at the time of cesarean delivery. Parturients with baseline myocardial dysfunction are at increased risk of cardiovascular decompensation in the peripartum period and close hemodynamic monitoring is warranted. We report our use of intraoperative non-invasive cardiac output monitoring during cesarean delivery under epidural anesthesia in a 24-year-old woman with dilated cardiomyopathy secondary to Marfan syndrome, aortic arch, aortic valve and mitral valve replacements and a left ventricular ejection fraction of 37%. Three distinct hemodynamic trends were noted. After achieving adequate surgical anesthesia with 2% lidocaine 20mL, cardiac output and stroke volume rose for approximately 20min from baseline values of 6.3L/min and 69mL, respectively, to 9L/min and 107mL. Values subsequently trended down and remained depressed for nearly 20min following delivery. The lack of immediate post-delivery increases in both cardiac output and stroke volume were attributed to acute blood loss, intravascular volume depletion from fluid restriction, and slow infusion of oxytocin. By the end of surgery, cardiac output and stroke volume ultimately increased by 66% and 84% of baseline values, respectively. Systemic blood pressure, heart rate and cardiac output did not appear to correlate despite the use of phenylephrine to manage hypotension. The patient remained hemodynamically stable with no evidence of acute volume overload.